Position Statement

Antibiotic Prophylaxis for Musculoskeletal Oncology Patients

This Position Statement was developed as a consensus from members of the Musculoskeletal Tumor Society.
More than 1,000,000 total joint arthroplasties are performed annually in the United States, of which approximately 7 percent are revision procedures. Deep infections of total joint replacements usually result in the need for extensive revision, which is extremely costly. Due to the use of peri-operative antibiotic prophylaxis and other technical advances, deep infection occurring in the immediate postoperative period resulting from intra-operative contamination has been markedly reduced in the past 20 years.

However, tumor patients are unique in their antibiotic requirements.Tumorpatients who have undergone limb salvage surgery are highly susceptible to infection. In addition, infections in these patients are extremely difficult to eradicate, even after irrigation debridement and revision. These patients are at higher risk than non-tumor patients risk for amputation as a consequence of an infection.;

Given the potential adverse outcomes and costs of treating an infected limb salvage surgery, the members of the Musculoskeletal Society feel strongly that SCIP measures about prophylactic antibiotics should not be applied to patients with bone and soft-tissue tumors who have undergone limb salvage surgery. Because of the significant potential morbidity with this patient population, there is no published literature comparing post-operative antibiotic prophylaxis. The members of the Musculoskeletal Tumor Society feel that the SCIP guidelines were clearly created in exclusion of their patients and adherence to these guidelines may have an unacceptable adverse effect on this patient population.

The reasons identified were:

SCIP measures are based on data obtained in the setting of primary arthroplasty.

The measures are not applied to revision arthroplasty in non-tumor patients.

Tumor patients are considered immuno-suppressed on the basis of the disease and therapy.

Large dead spaces result from the tumor resection and drains must be in place for lengthy periods of time.

We have documented a high rate of infection and wound healing complications in patients with limb salvage surgery (15%) compared to primary arthroplasty.

Radiation effects result in an increased risk of infection and wound healing complications.

There has not been a study of antibiotic prophylaxis in these patients.

The result of a deep infection is often the loss of the limb and a delay in the administration of potentially life saving systemic therapy.

These patients, as a result of prolonged and repeated hospitalizations, often are colonized with resistant bacterial flora.

This statement provides recommendations to support musculoskeletal oncologists in their clinical judgment regarding post-operative antibiotic prophylaxis for tumor patients. It is not intended as the standard of care nor as a substitute for clinical judgment as it is impossible to make recommendations for all conceivable clinical situations.

References:
Number of Patients, Number of Procedures, Average Patient Age, Average Length of Stay - National Hospital Discharge Survey 1998-2005. Data obtained from: U.S. Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics.